Healthcare Provider Details

I. General information

NPI: 1972390292
Provider Name (Legal Business Name): ALISON JEAN VANDENBERGHE MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 04/21/2025
Certification Date: 04/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST SPECIAL OPERATIONS MEDICAL GROUP
HURLBURT FIELD FL
32544
US

IV. Provider business mailing address

529 EMMY LN
HANOVER MN
55341-3100
US

V. Phone/Fax

Practice location:
  • Phone: 850-641-2337
  • Fax:
Mailing address:
  • Phone: 612-219-5405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86117786
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: